The pattern 4 ni this case lacks large cribriform morphology.
2. Prostate and Pelvic Lymph Nodes (Prostatectomy with Lymphadenectomy, S23-12074, 3/14/2023): The tumor shows focal ductal features.
The pattern 4 in this case lacks large cribriform morphology.
Arepresentativetumor block is A17 fi further molecular test is indicated.
Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length ofpositive margin changed to 1 cm).
The original diagnosis andtumor staging remain unchanged.
Addendum electronically signed by Jonathan Epstein I, MD on 5/3/2023So
I spoke with Dr. Epstein his stated radiation would be next.
My two oncologist state no to radiation to prostate bed
Another oncologist said absolutely yes to radiation
However, one of my urologist said not yet due to incontinence
Please help, my head is spinning I need some clarification as I’m so confused
Thanks
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Shorehousejam
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Your PCa in your bones vastly overrides any consideration of cancer in your prostate bed and pelvic LNs. Your cancer has been debulked and that is the best you can do. Radiation on top of recently cut tissue is destructive, and there is no known benefit. I assume you are still taking ADT+abiraterone, which is beneficial.
Yes,that is oligometastatic, which is why debulking the prostate made sense.
Your decision on debulking was prostatectomy or radiation, not prostatectomy and radiation. You chose prostatectomy. There is no known benefit to salvage radiation now that your cancer is in your bones. The only known beneficial therapy is systemic (hormones, chemo, etc.).
Prostate cancer spreads outside the prostate via blood, lymph or nerves. If the metastases disappeared when you took hormone therapy, they were prostate cancer,
I think it is bazaar to not radiate the prostate bed fossia, the nodes and any bone metastasis. Is that standard of care? or a trial that showed no benefit to All men? I’m confused as to where you got your knowledge on radiation being pointless
I don't understand your situation with bone mets. You wrote that you had lytic bone mets but then you claim they weren't - which is it? It is important to know to make this decision. If you have had bone mets, there is no evidence that such action will be beneficial. I'm not saying there is evidence of no benefit, I'm saying there is no evidence of benefit - see the difference? . But there is a good chance that it will result in side effects. If you have not had bone metastases, a wider field of radiation may be curative. So you have to be sure about it first and make your decision from there.
So the bone metastases were biopsied? How else would anyone know they were negative for adenocarcinoma?
If they were not metastases, you can still treat your pelvic LNs. You will have to wait for tissues to heal from your prostatectomy. Probably 7 months would be good.
I have a question on the addendum of my pathology report my margins were changed from 1mm to 1cm, see here:
Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length of positive margin changed to 1 cm).
That’s 10mm isn’t that insanely large margin? Wouldn’t the surgeon notice this and take more? What am I missing here?
ok so 1cm is the total of all EPE? Not all the way around…this I’m getting from the addendum on my pathology report below:
Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length ofpositive margin changed to 1 cm
Tall Allen had a important question regarding whether you really have lytic lesions or not: Your doctors think that because the bone metastases did not express PSMA that they were not adenocarcinoma?
I dont want to put words in his mouth but I think he is saying lytic lesions cant be confirmed by lack of PSMA expression. And more than likely the only confirmation comes from bone biopsy.
Right. I'm just confused or wondering if you actually have confirmation of the rare Lytic bone lesions instead of the Osteoblastic bone lesions which are more common.
The bone issue is confusing to me. Lytic bone metastasis in prostate cancer is rare as most are osteoblastic i.e. making bone. For local control pelvic radiation seems reasonable. If in fact the bone lesions are prostate cancer proven by biopsy then I would say the treatment of oligometastatic prostate cancer is evolving and some centers would treat your isolated bone mets.
Thank you, my wife and I find, that we really have to push these physicians to do what we want, not want they constantly repeat as if reading from a Standard of Care manual…good grief
Getting cutting edge care rather than cook book care is a constant struggle. You have to read a lot and really work at educating yourself. I wish you well in this struggle.
Your Post; "Rare atypical cells in a background of hemorrhage and scar. High-grade carcinoma cannot be excluded with certainty."
Have you considered, obtained or thinking about Germline and Genomic Testing. What I read is that either FH (family history) or rare/ a-typical/ unusual tumor or cell structures require both! These tests could reveal a treatment tailored to the a-typical condition found in your genetic or tumor cellular make up. Check these references;
As far as sRT (salvage radiation) on top of RP (prostatectomy) that is what I had. My PSA was recurrent at 6 weeks post op and I had sRT to the fosa, bladder neck (I had neck invasion as well), plus the pelvic lymph nodes (I had 11 nodes removed). What I read is that there is definite benefit to sRT either adjuvant (no recurrence of PSA) or as early salvage...check out these references;
...but sRT can cause Continence issues; it did with me. I was not dry-dry (100% dry) when I went into sRT and that condition was locked in place. I will leak 'for the duration,' but I went ahead w the sRT at the time knowing this. Check these links out;
Your pathology is different than mine (GS 4+3); GS 5 is spread by blood so you need to act with some urgency. But take some time to understand what the impacts of your decisions will be. Dont rely, expect or depend on your Dr's to tell you what these consequences will be...in my case I had to find out why a consequence happened and THEN react to it. But do your best, make a decision, then dont look back and roll with the punches. Let us know what happens...Rick
thank you RMontana for this detailed reply. I sent you a message with a question. And Shorehousejam thank you for asking this question. I hope you discover the best path forward through this very confusing journey.
Yes, this is what I have read and what my URO stated to me. I had 'Pattern 5 at the EPE,' which is stating there was some differentiation of my PCa cells at the margin! For that reason and the fact that I had a whopping 0.97 out of 1.0 score on Decipher I was considered Intermediate-High Risk. I proceeded with sRT (salvage) and did 15 months extra ADT, on top of 6 months prior to sRT, for a total of 21 months. Here is a study that determined that the combined percent of pattern 4-5 in the pathology sample was a better predictor of progression than the GS...check this out.
If you do proceed with sRT and the issue of concern is MET outside the fossa area then this study states its important to get PSA readings before, during and after sRT treatment! I did on my own and I am glad I did...most doctors will not do this unless you ask them...check this out.
If you are concerned about sRT before you are dry then this study may be of interest (if I have not shared it already). I was not 100% dry at start of sRT and I will remain this way for the rest of my life...but I did not want to wait and NO ONE would tell me that my PCa would not spread while on ADT...that it would 'slow down,' 'stop growing,' yes, but that it would not spread by blood no...so I did not wait beyond 6 months. But 67% of men go into sRT with Grade 1 leakage, which is Dry or with a 'Safety Pad,' which means that they are still leaking..check this out.
I am comfortable that for high risk PCa patients sRT and ADT have a positive effect. I have provided the references for this; let me know if you need them again. I also see some comments on this portal state that there is no benefit from sRT after a RP but I dont see the studies that back that up. Here is another not shared previously that supports sRT (actually adjuvant) radiation post RP...check this out; it also talks about patients with pattern 5 and the need for RT post RP...go to Min 21:14 for the explanation of the 'adjuvant gap,' which means, the possible undertreatment of 25-30% of cases that could benefit from radiation;
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Adjunctive vs Salvage Radiation?
Received results today from Axumin scan performed last Thursday. They plan to start me on ADT with radiation in 8 weeks. Thoughts welcome.
